Snoring or Obstructive Sleep Apnea (OSA) Syndrome is a medical condition that requires careful attention and proper treatment by a sleep specialist. This disorder, which can be life threatening if untreated, involves frequent collapse of the breathing passageway during sleep, resulting in partial or complete blockage causing changes in one’s breathing pattern and blood oxygen levels during sleep. Symptoms include excessive daytime sleepiness, poor performance at home or work, and depression.
During sleep, the muscles in your throat relax and are thus more likely to close now than when you are awake. The negative pressure of air pulled by the lungs through a narrow airway may cause the breathing passageway to collapse; much like when a straw flattens and collapses if you pinch one end and keep it closed while sucking on the other end. Early and appropriate treatment at a sleep clinic can prevent or reverse the serious consequences associated with OSAS.
If a sleep specialist has diagnosed you with sleep apnea, your doctor will have a number of treatment options for you to consider. Correcting your breathing problem during sleep may involve one or more of the following treatments.
Continuous Positive Airway Pressure or CPAP Therapy
Patients who snore and have Obstructive Sleep Apnea (OSA) are advised CPAP therapy. They will be educated by a trained Nithra Respiratory Therapist so that they may comfortably use the device at home to reduce snoring and other sleep related breathing problems.OSA can usually be completely controlled with PAP, but the patient must use it regularly whenever he or she sleeps. Getting used to sleeping with a PAP machine is usually not an issue thanks to the great benefit it offers, but may take a while for some to get accustomed to. The specialists at Nithra will offer tips and suggestions to overcome barriers and ensure you give the therapy a good try, without it being too inconvenient or troublesome for you, as it can really help you sleep better and more importantly prevent several long term health complications.
- CPAP Treatment is a highly effective therapy that uses air pressure to prop the airway open during sleep. CPAP machines work by pumping room air (In some patients additional oxygen may be required) through a compressor (to keep one’s respiratory passage open when asleep) that is connected by a hose to a mask that fits over the nose or the nose and mouth. The mask fits over the top of the head and is held in place with straps. With Obstructive Sleep Apnea, your upper airway collapses time and again as you sleep; PAP (Positive Airway Pressure) devices give you just the right amount of pressurised air needed to prevent this collapse. When properly set, these machines can eliminate your apnea and snoring, giving you a good night’s sleep.
- Various PAP machines and masks are available to purchase, allowing each person to find the combination of equipment (i.e. the mask that allows the pressurised air in) that works best. Some patients find that PAP therapy works best for them when using a mask that fits securely over their nose and mouth or in the nostrils. For most people, they first try PAP machines that deliver a continuous fixed amount of pressurised air, hence the name CPAP(continuous positive airway pressure), while some others may require two-level (or Bi Level) PAP machines (commonly referred to as Bi-PAP) as they deliver more pressurised air when breathing in and less when breathing out. Self-adjustable PAP machines (also called Auto-Titrating CPAP) will provide pressurised air only when apnea occurs. The treatment choices must be individualized based on clinical judgement by the sleep specialist.
- The PAP machine you use must be carefully adjusted to provide just the proper amount of pressurised air you need – in all body positions, no matter how deeply you sleep. To determine the correct amount of air pressure you require, the specialist at Nithra will plan a CPAP titration study either at home or in the Nithra sleep clinic to determine the correct pressure level one requires.
- An Auto-PAP device in use from 1996 in America, these automated PAP machines are believed to have made the treatment of sleep apnea more comfortable and effective. By increasing air pressure intermittently (in a regulated manner), an auto-PAP machine could limit your use of CPAP or two-level PAP. Ask your specialist at Nithra if this can work for you.
- Nasal pillows are an alternative to the mask method of PAP delivery. These are soft pieces of plastic that are placed directly into the nostrils. Several brands of PAP are currently available and it is best to discuss with your healthcare professional and seek his/her recommendations.
- While most patients fare well with PAP therapy, a few may experience dryness in the nose or feelings of claustrophobia. These and other problems can be overcome with a few adjustments.
Side effects of PAP Therapy
The positive effects of PAP therapy such as immediate reduction in snoring, improved and restful, refreshing sleep are often noticed in a few days. Some patients experience what they describe as side effects which are described below. It is important to address these early with the Nithra team to ensure better compliance and outcome of the treatment.
Nasal discomfort – Nasal stuffiness or congestion is the most common side effect of PAP therapy and is often a nasal reaction to the airflow from the PAP device. Many patients experience some increased nasal stuffiness and symptoms like nasal itching, runny nose, nosebleeds and nose dryness when they first begin PAP treatment but these symptoms disappear within a month of use.
- One way to help the nasal symptoms is by applying a few sprays of nasal saline solution (a combination of salt and water available as a spray) in each nostril before using PAP – this solution can be directly got from a pharmacy without a prescription. Oral antihistamines and decongestants, advised by your physician will also be useful to control PAP-related nasal discomfort. Decongestant nasal sprays though helpful, should only be used for a few days since regular nightly use may become habitual and can lead to increased nasal congestion.
- PAP devices can be also connected to specially designed humidifiers that will greatly reduce nasal symptoms. Humidifiers add moisture (either cool or heated, depending on what works in your favour) to the pressurised air that PAP devices use. A PAP humidifier must be prescribed by a healthcare professional only and should be carefully maintained according to the manufacturer’s instructions to avoid nasal and sinus infections.
Mouth discomfort – PAP devices may cause dryness and some pain or discomfort in the throat from air-blowing through an open mouth. A chinstrap helps to keep the mouth closed or a mask that covers the nose and mouth can also eliminate this complaint. Humidifiers too can aid in keeping mouth discomforts at bay.
Other discomforts and how to manage them:
- Mask air leaks from PAP machines can cause sore, dry or red eyes, the loss of beneficial effects and even the return of snoring or apnea. A poorly fitted mask is often the culprit so ensure that your mask is of the right size with a chinstrap. Try reapplying the mask and readjusting the headgear. If you continue to experience significant air leaks despite using a chinstrap, consider a mask designed to fit inside your nostrils (nasal pillows), or one that covers your nose and mouth. When your mask and PAP therapy starts working well for you, remember to check the same for any wear or tear regularly. Please do not hesitate to contact Nithra specialists for any help in this regard.
- Redness on some parts of the face where the mask contacts the skin occurs when your mask is pressed too tightly to your face. If you develop red patchy areas or sores above the bridge of your nose or on your forehead, your headgear has to be loosened and the mask has to be re-fitted and adjusted to eliminate air leaks without undue pressure on your skin. Using spacers and air cushions can help ease the pressure points, but remember not to loosen your mask so much that leaks develop. Ask your PAP supplier to help you with a correctly fitting mask and appropriate nasal pillows. If you think you might be allergic to a mask, try applying a paper tape (Micropore™ or Band-Aid™) over the areas where the mask touches your skin. Fortunately, modern PAP masks are made of materials designed to minimise allergic reactions.
- Too much air pressure coming through the nose is a complaint from many first-time PAP devices users .To avoid this sensation, doctors usually prescribe a pressure ramp which starts the machine at a very low pressure and gradually raises it to the right amount over a fixed amount of time. Most PAP machines allow you to adjust your ramp time and many people find they prefer longer ramp times (10 to 20 minutes), at a low pressure; when they first start using PAP. As you get used to PAP or if the air pressure doesn’t bother you, set your ramp to shorter times to get the full benefits of PAP therapy after discussing with the Nithra specialists.
- If you have trouble breathing out against the continuous air pressure of CPAP, a two-level PAP machine called BiPAP™, may be suggested by your Sleep Specialist at Nithra. These machines sense when you breathe in and out, and deliver one pressure of air when you breathe in, and (usually) a lower pressure when you breathe out. Your sleep specialist at Nithra will advise you to use a two-level PAP if you find that the air pressure with CPAP feels too high or that you are working too hard to breathe out. A lower pressure when you breathe out may feel more natural to you. The two-level PAP machines are sometimes more expensive that CPAP devices and only trained technicians and specialists from a specialized sleep center like Nithra can correctly determine whether you require a two-level PAP device.
- Some people experience feelings of claustrophobia, difficult breathing, choking, or suffocation when first using PAP – please let your doctor or PAP machine supplier know if you feel this way, without delay. It helps to practice with your PAP machine during the day while awake, watching television or reading. Specialists at Nithra advise that you start by wearing the PAP device for only a few minutes in the beginning and gradually increase the time you spend breathing with it until you feel comfortable. At first, some people fight the pressure and tend to hyperventilate; practicing to breathe normally with the mask calmly, will help you. If you don’t like the mask over your nose, try a mask that fits in or just under the nose, with the correct air pressure. You may be advised to try a longer ramp time or two-level or self-adjustable PAP. It definitely helps to learn a relaxation technique too from a trained professional. Our specialist at the Nithra sleep institute can assist you. Some amount of this discomfort during the initial therapy is not unusual, so give PAP therapy a chance and it will work for you.
- All PAP machines make some amount of noise thought the newer ones are much quieter than older models. Placing the machine under the bed or on the floor usually solves this problem, but ask your PAP supplier for assistance on the same.
Frequently asked questions about PAP devices
Regular cleaning is essential to assure proper function and safety of PAP devices. The method and schedule for cleaning hoses, masks and changing filters differs for each PAP device, so please refer to the manufacturer’s instruction manual for details on the maintenance of your PAP equipment. Improper care of PAP devices; filters, mask and hoses can lead to nasal and sinus problems, congestion and even infections.
Most of the common complaints about PAP relate to the fit of the mask and drying of the airway. The remedies Nithra suggests should solve the majority of these problems and if you have any other symptoms or concerns, our specialists are available to help. PAP helps most people with sleep apnea when you allow yourself time to get comfortable with it. Be patient and you’ll see how it can improves your life.
More ways to treat OSA
- Sleep – position training: Sleeping on your back allows gravity to pull on the soft tissues at the back of your throat and neck causing the breathing passageway to narrow or collapse completely. Sleep- position training will help you remain asleep on your side at night which can lead to an improvement in your symptoms. A simple approach called the ‘tennis ball technique’, involves sewing a pocket onto the back of your pyjama/nightwear top and inserting tennis balls into it. If you roll on to your back during sleep, the pressure from the balls will encourage you to roll onto your side. Commercial devices are also available to help you stay on your side during sleeping.
- Weight loss and regular exercise: For some people, losing weight alone helps in their treatment. Once you reach your desired weight, it is important to maintain that because snoring and apnea are likely to return with weight gain. If you are overweight, our healthcare professional and nutritionist at Nithra will guide you with weight loss programs.
- Oral appliances: These devices work to keep your airway open by holding the tongue or jaw forward thus increasing the airway space behind the tongue. A clear airway is most important for any of these devices to treat you successfully. They will be fitted by our experienced and well-trained specialists at Nithra.
- Tongue – retaining devices: This must be placed in your mouth just before bed as it creates a slight suction which holds the tongue forward to keep it from falling back into the throat. They are effective in people who have mild to moderate apnea.
- Jaw – advancement device: These appliances are made to fit the top and bottom teeth in a way that pulls the lower jaw slightly forward.
An operation or surgery may be advised by the specialist at Nithra if he or she identifies an obstruction in your airway that is not fixable with more conservative treatments. Whatever surgery is recommended, you will be educated on all the possible risks and side effects before proceeding. While an operation can be an effective treatment for some patients who may have an advanced disorder, it is not the option for everyone.
- Nasal surgery is used to remove blockages in the nose (such as growths) or to repair a deviated septum (a displacement of the wall that divides the nose into halves). This operation may be one part of an overall treatment plan to cure you of apnea and is generally used along with other forms of treatment or other operations.
- Laser Assisted Uvulopalatoplasty (LAUP) is a relatively new procedure used mainly for the treatment of snoring. With LAUP, the surgeon uses a laser to remove part of the uvula and soft palate- this procedure takes place over several sessions in a doctor’s office. While this technique appears promising, patients need to be aware that its effectiveness in the treatment of sleep apnea has not yet been completely evaluated.
- Uvulopalatopharyngoplasty (UPPP) is an operation that involves removing the uvula; the soft, fleshy projection that hangs in the back of the throat, the tonsils, and part of the soft palate. Approximately 50% of patients who undergo this operation are helped by it initially but may have recurrence of symptoms over a period of time. Side effects such as severe throat pain, nasal sounding speech, and the regurgitation of liquids into the nose when swallowing, have been reported.
- Inferior Sagittal Mandibular Osteotomy (ISO) and Geniohyoid Advancement with Hyoid Myotomy (GAHM) are procedures that enlarge the airway. ISO is an operation that includes bringing the lower bone of the jaw forward and the GAHM operation involves attaching the hyoid (the U-shaped bone where your bottom teeth are located) to the windpipe. The effectiveness of these operations can depend on a person’s weight and lower jaw structure.
- Maxillo Mandibular Advancement (MMO) is a reconstructive surgery involving the cutting of the bone that connects the jaw to the face and then moving the upper and lower jaws forward. This operation is done under general anaesthesia and requires a hospital stay of a few days. After the operation, the jaw is wired shut to hold it in place for about 4 weeks. A liquid diet necessary at this time brings about weight loss. Once the wires are removed, orthodontic work may be needed to realign the teeth so they fit together properly. This treatment is time consuming and expensive, but its results are largely positive for patients. The best candidates for this type of treatment are those born with a smaller – than – normal jaw or a jaw that is set too far back.
- Laser Midline Glossectomy (LMG) and Lingualplasty are rarely performed operations. They involve enlarging the area behind the tongue by removing a portion of the back half of the tongue.
- Tracheostomy is not often used to treat sleep apnea and is only applicable to an immediately life threatening sleep apnea condition and it involves the creation of a small surgical opening in the windpipe. The tracheostomy by passes any obstruction in the throat and allows air to flow freely into the lungs while the patent is sleeping. The opening is covered during the day and normal breathing and speech resume.
Medication and Alternative Treatments
Medication will be advised for several patients and they are most useful in cases of mild apnea or when used as part of an overall treatment program.
Over-the-counter, prescription nasal sprays help clear the nasal passages, but they can be habit-forming and should not be used for more than a few days. Though they unblock the nose, they sometimes take many days or weeks to work. Nasal sprays will not be helpful if there is a permanent blockage caused by a growth or a deviated septum.
Medication to relieve congestion in the nose is helpful but it isn’t considered to be a treatment for sleep apnea. Although decongestants may help you breathe better, they can cause difficulty falling asleep, staying asleep or both.
Protriptyline was one of the medicines used to treat mild cases of apnea although of limited value. It is an antidepressant that decreases REM (dreaming) sleep; a time when apneas are likely to be longer and more frequent. Protriptyline helps to strengthen the muscles of the throat but can produce mild side effects like dry mouth and constipation, and is thus not recommended for people with high blood pressure or an abnormal heart rhythm. A less – frequently prescribed medication for the treatment of OSA is medroxyprogesterone; a hormone which could produce side effects like unwanted hair growth, mood changes and fluid retention.
This treatment may be used to correct low oxygen levels in the blood due to heart or lung disease. It may be used along with PAP therapy for best results in some patients.
No matter which form of treatment is used for sleep apnea, it is important that you follow up regularly with the sleep professionals at Nithra to determine its success and also address any issues early. The sleep clinic will schedule regular follow – up appointments for patients as it is essential to monitor the severity of one’s apnea with age. If your snoring resumes or if you are sleepy during the day, it may mean the apnea has returned and this calls for a review to determine if additional treatments may be necessary.